Introduction
This paper explores the issue of mental health. It will briefly explain the main theoretical approaches to the issue, before presenting a case study and a model that I have found useful in my work as a counsellor/psychotherapist supporting people to achieve and sustain positive mental health.
Understanding Mental Health
Life can be difficult. Every day we are presented with a series of challenges and choices to make. Our ability to cope with these challenges is a reflection of our mental health. When faced with everyday decisions, such as whether or not to get up in the morning, most people can cope quite well, and will make good choices most of the time. For some people however, even the most basic of everyday tasks can seem overwhelming. These people are deemed to be in negative mental health, or mental ill health (1).
While Carr (2007) suggested that one in four Irish adults will experience mental health difficulties at some stage in life (2), a recent study (3) of 2,500 teenagers in Ireland between the ages of 13 and 18 revealed that only 30% of those surveyed identified their mental health as good or very good. This suggests that just like with physical health, most people experience periods of both positive and negative mental health at some stage in their life.
Negative mental health exists on a continuum from mild to severe. The majority of people who experience it on the milder end of the scale find their own way of dealing with it. For those who seek professional help however, therapeutic responses fall into two broad categories, biological and psychosocial. The biological approach has its origin in psychiatry, the mental health specialism of general medicine. In psychiatry, symptoms of negative mental health are assessed in accordance with criteria set out in the diagnostic manual the DSM-5 (4) and the patient is diagnosed and treated accordingly. Treatment may involve chemical (drug) based responses, counseling/psychotherapy or a combination of the two.
The psychosocial approach suggests that mental ill health is caused by the psychological impact of trauma, or difficult life experiences. The trauma may stem from the client’s past or present life situation. For those who subscribe to this approach, counseling or therapy is likely to be the preferred response.
The distinction is made here between counseling and therapy. Counseling is where two parties meet, each party usually (though not always) consisting of one person. The counsellor facilitates a process of therapeutic change by enabling the client through talking, to find solutions to, or find better ways of coping with the challenges of life. There is an ongoing disagreement within Irish counseling about the professional title that should be used. It centers on the use of the term counsellor or psychotherapist. Since the profession is not yet (2017) regulated in law, practitioners can use whichever term they prefer. While the issue remains unresolved, there is general agreement that psychotherapy refers to a form of in-depth talking counseling.
Within counseling/psychotherapy there are three broad schools of thought. While they all aim to help the client to find more effective coping strategies for life, their theoretical understanding of the problem is quite different. The Psychodynamic approach tends to focus on the importance of early childhood experiences and the struggle between the conscious and unconscious self. The Cognitive Behavioral approach tends to focus on thought process and gradual thought based behavior modification, while the Humanistic approach tends to focus on human relationships, the individuals capacity to reach their full potential and the emotional and spiritual influences on mental health. According to Carr (2007) counseling/psychotherapy has proven to be helpful in 65-72% of people presenting with mental health difficulties (2). He did not identify any significant difference in success rates between the different approaches. In recent years, there has been a growing number of practitioners who identify themselves as integrative counsellors/psychotherapists and who’s training in influenced by all three schools of thought.
The general concept of therapy is much broader than counseling/psychotherapy and is used to describe a range of services/interventions aimed at providing emotional, psychological, physical and spiritual healing to the individual. There are over 400 types of therapy internationally from approaches that use drama, dance and art to those that focus on breathing and energy flow in the body (5).
The benefit of the more creative approaches to therapeutic work is that traditional talking counseling/psychotherapy is only of any benefit to someone who can talk, and has the emotional and intellectual capacity to engage in the counseling process. Creative therapies, however, can be used with a far wider variety of clients such as children or adults with speech and language or intellectual difficulties.
Which Approach is Correct, the Biological or Psychosocial?
In reality, both the biological and psychosocial approaches to mental health have their merits and limitations. That is why many mental health professionals operate from what is called a bio-psychosocial model. This model acknowledges that some people need medication in order to function in life. Some benefit from just engaging in counseling or talking therapy, and some require both counseling and medication for the best possible outcome.
There is a difference of opinion between the counseling and medical professions in Ireland about the use of medication in the treatment of some mental health difficulties (such as depression or anxiety). Counsellors traditionally think that the medical profession is inclined to over medicate, while the medical profession sometimes think that counsellors influence some people to come off their medication prematurely. Both arguments are probably fair, and in recent years it has become more common for doctors to prescribe medication to stabilize a patient with depression or anxiety, but they may not repeat the prescription if the patient does not access a counseling support service. These cases are where the doctor believes the patient’s difficulties to be psychosocial in nature. Similarly, counsellors often refer clients to a GP for medication, if the client’s mental health is deemed to pose an imminent risk to their health/safety and welfare.
Case Study
A number of years ago a man presented to me with depression and suicidal ideation. He was being treated by his doctor with medication but he was also advised to attend counseling. The man was middle aged and had decided that he did not want to live any more as he could no longer carry the shame and guilt of having sexually abused his own daughter over 40 years earlier. To the best of the client’s knowledge, his adult daughter had no conscious recollection of the incidents which remained a secret that he had never told anyone prior to his engagement in counseling.
On exploration of the client’s life story, it became apparent that he had experienced ongoing and systematic sexual abuse as a child by his father, who prostituted his children to men that he brought home from work. For the first fifteen years of the client’s life, his sense of sex, sexuality, gender, relationships and love were utterly distorted. His life was then further complicated when he discovered alcohol, which he became dependent on into his early adult life.
The client engaged in the counseling process and the incident was reported to the state child protection services who conducted a full investigation before deciding not to proceed with the issue. The client remained in counseling for nearly twelve months, and to the best of my knowledge, he is still alive today.
This case highlights the complexities in the lives of some people with negative mental health. While there is no doubt that medication helped this client to stabilize himself, and control the impulse to harm himself, it was by talking through his life situation that he learned to find more effective coping strategies to deal with his mental health issues.
Achieving Positive Mental Health
There are four key cornerstones to positive mental health. I ask my clients to pay attention to each of these issues, because I have found that doing so helps them to stabilize their general mental health, which increases the likelihood of a positive outcome from counseling. The advice I give is as follows;
Diet
The more chemicals that you put into your brain and central nervous system, the less likely it is to function well for you. Identify a short and achievable period of time (4-6 weeks) and reduce or avoid alcohol, nicotine, caffeine and all non-medically prescribed mood altering chemicals (particularly illegal ones). If you are a heavy smoker or chemical user, you may need to consult your doctor for a managed detoxification program.
Eat your food in as natural a state as possible, avoiding processed foods where possible. Slow energy release, complex carbohydrates such as oatmeal and brown bread/rice/pasta will help to regulate the mood swings caused by their high sugar alternatives. Eat plenty of fruit and vegetables and drink at least one litre of water a day. A healthy diet does not have to be drudgery, allow your-self some treats, but make them healthy ones. Be creative with your diet and do not think about life long changes, you will only get bored and loose interest. Just commit to 4-6 weeks and see if you notice a difference in your general energy and sense of wellness.
Lifestyle
Get 7-9 hours of quality sleep per night. Avoid sugary food, caffeine or mental stimulation including use of internet or social media before sleep. Sleep is where the body and mind regenerate themselves. If you do not get enough sleep you will start the day tired and it is harder to cope with the challenges of life. Work toward reduced stress, and balance in all things in life (particularly work/life balance). Be open and honest in your communication with others. Do not bottle up (even the smallest of) issues. Small issues accumulate over time, and can cause very significant stress in relationships, and in life. Allow time in the week just for yourself. Find a hobby that you enjoy, but do not withdraw from relationships to do it, as isolation compounds negative mental health.
Exercise
Do 40 minutes of moderate cardiovascular exercise twice a week. It does not matter what you do, provided you sweat, and challenge your body. Exercise produces endorphins in the brain that are nature’s anti-depressants and research shows that it has a positive impact on mental health (particularly for people with depression and anxiety). Consult your doctor before engaging in exercise if necessary. Try to do exercise that involves other people; they will help to motivate you when your energy or desire to train is low. Physical work or running around after small children does not count as therapeutic exercise, no matter how labor intensive it is!
Purpose in life
We all need a reason to get out of bed in the morning. Have a goal, a meaning or a purpose. It will help you to motivate yourself, and keep you moving forward in life. Sometimes something as simple as owning a pet can be enough responsibility to get people out of bed. For others, it is work/college, family or community service. Some people find purpose and meaning in faith. Find whatever works for you, but do not allow yourself to be defined by it. If you allow your entire identity to be wrapped up in a single issue such as your job or role as a parent, then you are left with no purpose if you retire/lose your job, or your kids leave home.
I am not suggesting that just paying attention to Diet, Lifestyle, Exercise and Purpose in Life will be enough to create and sustain positive mental health. Living with a mood disorder such as depression is incredibly difficult. It is like being in a black cloud all of the time. The unfortunate reality though, is that change does not, and will not happen by itself. You have to make it happen, and sometimes that requires doing things that are not easy to do. If it feels too hard to make significant changes to your life right now, take it in bite size pieces and do what you can. Every step in the right direction will help to improve your situation. One thing is for certain, if you do not pay attention to these issues, and continue with self destructive habits, then all the counseling in the world will not make any difference to your situation.
Mindfulness
Many people attend counseling for one of two reasons. They are either holding onto issues from the past, or they are fearful of issues in the future. While the past is significant, and it undoubtedly shapes and moulds who we are, the reality is that we cannot change it, so there is very little point in allowing ourselves to be defined by it. Similarly, none of us can predict the future, and since it hasn’t happened yet, there is not much point in focusing too much energy on that either. The only time that is real (and that we have some relative control over) is the present, so from a counseling perspective it is far more helpful to manage our stress in the now, rather than getting caught up in the past or the future. This is the principle behind mindfulness based stress reduction (Kabat-Zinn, 1990).
When my clients have paid attention to diet, lifestyle, exercise and purpose in life, the work shifts to coping strategies for the here and now. At its most basic level the work involves teaching the client to identify when they are beginning to feel overwhelmed and to regain control by asking themselves the following questions;
- What’s happening?
- What am I thinking?
- How am I feeling?
- What are my options in this situation?
- What is the best option?
I have found that by practicing this model, the clients regain impulse control and increase their likelihood of making good choices in life, and therefore improving their general mental health. They also often report a general improvement in the quality of all of their relationships.
All of this happens in the context of a counseling relationship where the primary focus is on the client’s present life situation, but where the past is also explored in so far as it helps the client to understand who he is in the present.
Conclusion
My hope is that this chapter helps to de-mystify some of the jargon that is often associated with the issue mental health. Everyone will experience periods of positive and negative mental health across their lifetime. It does not necessarily mean that their condition is permanent; it just means that right now they are struggling to cope with the challenges of life.
There are lots of people who claim to be experts on mental health, and who will argue the merits and limitations of the biological and psychosocial approaches to the issue. The only thing that I am an expert on is me, (and sometimes I am not even sure about that!). I do not claim to have the definitive answer to positive mental health. I do know one thing though; if you are struggling to cope with life, doing nothing is not the answer. There is no shame in taking medication, attending a counsellor or beating drums and chanting by a campfire in the moonlight (if that is your thing). The aim is to achieve balance and mental wellness. Trust your own internal wisdom, and find whatever works for you, bearing in mind that life does not always have to be good. It just has to be good enough.
References
- Corry, M. and Tubridy A. (2001). Going Mad, Understanding Mental Illness. Dublin: New leaf Publications
- Carr, A. (2007). The Effectiveness of Psychotherapy: A Review of Research by Prof. Alan Carr. Wexford: Irish Council for Psychotherapy
- O’Sullivan, C. (2017) Teen Mental Health Survey. Irish Examiner News Paper (30/03/2017)
- A.P.A. (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric association
- Corsini, R. and Wedding. (2008) Current psychotherapies, New York, Brooks/Cole
- Kabat-Zinn, J. (1990) Full Catastrophe Living; How to cope with stress, pain and illness using mindfulness meditation, Piatkus, London
*John Byrne is a psychotherapist and Lecturer at the Waterford Institute of Technology. This paper is from the book Mental Health For Millennials, Volume 1 published by Book Hub Publishing (2017).
